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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-67817� 3/7 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> 7GV <br /> THIS PERMIT EXPIRES I YEAR FROM DATE ISSUED Date Issued <br /> -(Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION , C,, �ACENSUS TRACT <br /> Owner's Name RA Phone ? 1 <br /> Address Cityj� SCA -�)�'1!� <br /> Contractor's Name License #� )3 Phone ^el- <br /> TYPE OF WORK (Check) : NEW WELL /�EPEN /_% RECONDITION /_� DESTRUCTION /_7 <br /> PUMP IAL <br /> NSTLATION /DUMP REPAIR / / PUMP REPLACEMENT /7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTICTANK±� c_SEWER LIPIES PRIVY <br /> SEWAGE DISPOSAL FIELD �7,_USSPOOL/SEEPAGE PIT�a-?.�OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: `of Well-Excavation <br /> 4--D-ome s tic/private r - Drilled Dia. of Well Casing 570 <br /> Domestic/public _ Driven ; —Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Sea r -4 <br /> Other otary Type of Grout <br /> Other Other Information t <br /> f, <br /> PUMP INSTALLATION: Contractor C^ <br /> yType of Pump H.P. <br /> PUMP REPLACEMENT: v '/ / State Work Done <br /> PUMP .REPAIR7.- - — _ —... � <br /> State Work Done �� �`" -" <br /> ESTRUCTION OF.WELL: Well Diameter a ,.,ri. Approximate Depth r <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District' 4 <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a , <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above <br /> info ation is true to the best of knowledge and belief. <br /> SIGNED TITLE <br /> (D PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHAS <br /> APPLICATI EPTED BY DATE k- y <br /> ADDITIONAL COMMENTS: <br /> PHASE Ij GROUT INSPECTION PHA IIJFINAL INSPECTION t <br /> INSPECTION BY DATE E! INSPECTION BY DATE - , - <br /> CALL FOR A GROUT INSPECTION .PRIOR..TO GROUTING AND FINAL INSPECTION. <br /> E H 1426 - 7/72 IM <br />